Diabetes

Today, we received the news via the WHO and Imperial College London that women in South Korea and other industrialised nations will have an average life expectancy of 90 years by 2030. Progress on longevity would seem to be inexorable. Yet will this really turn out to be the case? A recent news story concerning the death of a 70 year old woman in America seems to throw this positive scenario into doubt…

In January, a BBC News headline ran, ‘Bug resistant to all antibiotics kills woman’. No fewer than 26 different antibiotics had been tried in an attempt to keep the woman in question alive, following an infection she’d picked up after a long stay in India (a nation well known for long-term and widespread misuse of antibiotics.) Of the 26 used, even Colistin, the drug of ‘last resort’ – one that’s kept under lock and key for only the very worst cases – had failed. Samples of the infection taken from her wound were sent to the Centre for Disease Control, which established she was infected with Klebsiella pneumoniae – a species of bacteria that normally lives in the gut without causing disease, but had spread out of control.

It’s well known that prescribing antibiotics un-necessarily, and their misuse by patients, breeds bacterial resistance, rendering specific antibiotic drugs powerless over time. However, despite being someone who communicates regularly about health and disease, I was genuinely shocked by reading the slim, yet, powerful, Penguin paperback, The Drugs Don’t Work, by Professor Dame Sally Davies. Davies is the first female Chief Medical Officer for England, and an inspiring communicator. For sure, it takes highly effective communicators to get any ‘prevention is better than cure’ message across. As humans we are our own worst enemies, thanks to our ability to mentally discount potential threats…

The book starts with a whistlestop tour of antibiotic history, from the infamous accidental petri-dish discovery by ‘messy’ Alexander Fleming of bacteria-eating mould (penicillin), its timely mass production during WWII, through to development of other classes of antibiotic that have revolutionise not only medicine, but daily life – for the majority of the world.

A surgeon filmed by our team recently stated that without effective antibiotics, there’d be no surgery as we know it. Consider this: women undergoing C-sections (around a quarter of births), those undergoing hip or knee surgery, and many other surgical patients are routinely given these drugs as a preventative measure – as are chemotherapy and radiotherapy patients, whose immune systems are compromised.

Davies’ book serves as a warning in its largest sense: We have been using and abusing these life saving medicines to the extent that they are becoming redundant because, in the true Darwinian sense, survival of the fittest prevails: ‘bugs’ always fight back. Put simply, when antibiotics are abused (courses not completed by the patients, the wrong drugs prescribed, over-use by the veterinary and farming industry) any bacteria that survive the medicine will pass on resistance via their genes to the next generation of resistant bacteria.

A GLOBAL DECLARATION: TO ‘DIAGNOSE FIRST, NOT JUST TREAT’

Such is the seriousness of this ‘ticking time bomb’ that history was made in September 2016 when AMR became the subject of a United Nations High Level Meeting – only the fourth time ever that a health topic has made it onto the agenda.

The result was that 193 countries signed a declaration committing their nation to tacking the crisis, with a specific commitment to focus on innovative ways to improve diagnosis. (Only by diagnosing first, rather than prescribing antibiotics in an ‘un-targeted’ way, will this class of drug continue to be effective.)

Worrying, the pharmaceutical industry has not kept up with a regular stream of new antibiotics in their drug pipelines because they see little profit in it. Their view is that the cost of development is not matched by the potential return on investment, partly as antibiotics tend only to be used for a matter of days rather than months or years, unlike drugs for diabetes, dementia, cancer and so on. Added to this, antibiotic misuse leads to resistance, shortening the overall saleability of their drug. Interestingly, a potential solution Dame Sally poses is extending the patent period from 20 to 25 years.

SOLUTIONS ARE NEEDED FAST!

Certainly, solving the problem of antibiotic resistance won’t be easy, but Davies’ book offers several options. One of the most interesting involves the genomic revolution, whereby the ‘troublesome’ bacteria’s genetic code is mapped in order to tailor a precise treatment – rather than using the blunter option of treating it with a broad-spectrum drug (that would also kill off harmless bacteria).

Gene mapping can now be done for as little as £100 and is becoming an ever faster technique, which can make all the difference for the patient (given a population of bacteria can double in number of hours under the right conditions). That said, Davies cites the case of a major pharmaceutical company that spent 7 years testing over 500,000 compounds in 67 screening programmes against potential bacterial targets: In the end, only 5 showed any promise, and not a single compound made it to the clinical trial stage.

Yet, far from only predicting apocalypse, Davies implores scientists and governments to work together to find solutions to counter the frightening scenario of going to the medicine cabinet, only to find it bare. For sure, incentives must be in place. As long ago as 1795, Napoleon, knowing an army ‘marches on its stomach’, put up a reward of 12,000 francs for whoever discovered a way to preserve food for his troops. Not long after, Nicholas Appert invented the canning process, using heat treatment of food in sealed champagne bottles. (We hope the champagne wasn’t wasted…)

If Napoleon can do it unilaterally, surely we can club together at a global level to find new antibiotics to replace the ones that aren’t working. In the meantime, we must all preserve antibiotics for their right and proper use, and this requires education: Teaching people from a young age about microbial resistance will help, via projects such as the Europe-wide E-Bug www.e-bug.eu – tailored for various ages using engaging content such as animated characters to explain how resistance occurs. Teaching adults, too, is all-important, and the media have an important role: they recently reported that Klebsiella, which killed the woman above, is becoming resistant to chlorhexidine, an antimicrobial contained in some mouthwashes. Should we as consumers ask if this ingredient is essential to keep teeth and gums healthy, or must be saved for hospital?

EYES ON THE PRIZE

Coincidentally, there’s an C18th spirit surrounding the Longitude Prize which was set up in 2014 by British lottery-funded charity, Nesta. The project will donate £10m to an organisation that finds an easy, cost-effective test for bacterial infections which can be used by medics to determine if, and, when, to give out antibiotics. At this year’s annual meeting of the World Economic Forum at Davos, Switzerland, Dame Sally announced £250,000 in Discovery Award seed funding for tests that could win the main Longitude Prize. Expect to hear more about use of adjuvants – ‘resistance breakers’ and ‘antibiotic potentiators’ in future…

Some key facts:

Antibiotics add 20 years to our lives, on average

No new class of antibiotics has been discovered since the 1980s

Resistant bugs kills 25,000 per year in Europe, the same number dying from road traffic accidents

SCRUB UP! Practice regular hand washing for 20 seconds with soap and hot water – especially before eating. A study of 3,700 people at bars in Michigan showed that 1 in 10 people didn’t wash their hands, and a third didn’t use soap after using the lavatory!

This blog looks at some of the facts about Vitamin D, and intriguingly, how a lack of the ‘sunshine vitamin’ is being implicated in a host of diseases never previously associated with it. Vitamin D allows us to absorb calcium, iron, magnesium and zinc, and is crucial for tooth and bone development. Around 80% of our vitamin D is synthesised by our body when our skin is exposed to sunlight, so the further we live from the equator, the more we rely on our diet for the remaining 20% we need.

In England, all pregnant and breastfeeding mothers are advised to take daily 10mg vitamin D supplements to ensure adequate foetal stores for early infancy, addressing the fact we live in a climate where sunlight levels are low. (Observational studies have shown that a mother’s Vitamin D level during pregnancy can even influence the growth of her infant. In addition, Vitamin D drops are advised for children aged 6 months to 5 years. Yet, recent research commissioned by health insurer, BUPA, points to only 1 in 25 parents doing so.

And although vitamin D was discovered in the early 1900s, more and more is being discovered about its role in diseases affecting both young and old, such as osteoporosis, multiple sclerosis and even diabetes.

RICKETS: A HORROR RETURNS

Over the past few years, doctors and public health workers have been saddened to see Vitamin D deficiency return in the form of rickets. Rickets is characterised by misformed bones, dental issues, and muscle weakness. It occurs when the process of mineralisation – bone building – goes wrong. It may be due to over-use of sun block, not getting into the sun enough, or for cultural reasons involving covering up of the skin. Despite having high sunshine levels, the Middle East has the highest rate of rickets in the world, due to such cultural practices, and due to a lack of vitamin D supplementation for breast-feeding women.

FORTIFIED BRITAIN?

In England, the post war decades saw food being fortified with Vitamin D, which was added to margarine and some cereals. It was thought rickets had been entirely eradicated, but in the 1970s, it reappeared when different ethnic groups migrated to the UK. Children of Asian, Afro-Caribbean and Middle Eastern parents with darker skin required more sunlight exposure to get enough Vitamin D, so those children were more likely to develop rickets.

In 2010, the British Medical Journal reported that doctors in Newcastle (where sunlight levels are lower than in the South of England) were seeing 20 cases per year. It would seem that good patient education for this entirely preventable disease is of great importance once more. But is supplementation or food fortification needed? With our wealth of ethnicity, and so many variations in our diet, some say fortification would fail to provide a ‘catch all’ approach. Yet, as a nation, we don’t seem to have taken this deficiency to heart. In 1999, Britain was the only EU country that didn’t have an RDA (recommended daily allowance) for it.

CAN’T BITE, CAN’T FIGHT

We’ve come a long way in the past 100 years to understanding nutrition. When soldiers were recruited to fight in the Boer War (1899 – 1902) of the 8,000 men from Manchester who joined, 6,800 displayed signs of incapacity caused by childhood illnesses, including rickets, which presented significant drawbacks from a military strength point of view. Such was the poor state of the recruits’ teeth, thanks to a lack of Vitamin D (and poor oral hygiene), that the expression ‘Can’t bite, can’t fight’ was coined. Intriguingly, medics noted that Scotsmen fared better than most, which they put down to habitual doses of cod liver oil – even before Vitamin D had been discovered! The Scots’ belief was dismissed at the time as an old wives’ tale, and sadly it took decades before the truth emerged: oily fish does contain high levels of the vitamin.

NEW DISCOVERIES: LINKS TO MS, DIABETES AND MORE

Today, with genetic profiling and other lab techniques, we are discovering even more benefits of the sunshine Vitamin. Deficiency has been linked to the debilitating disease, multiple sclerosis, MS, for a long time. It is a disease almost unheard of near the equator, with incidence rising incrementally towards the poles, where sunshine levels are lowest. Although MS affects women more than men, as far back as the 1960s, it was noted by the military (which keeps helpful, large data sets of medical records) that a healthy, outdoor lifestyle amongst US veterans provided the ideal protection from MS.

The powerful effect of the seasons – ergo, Vitamin D – can also be seen in the number of those suffering immune disorders. Even within Britain, there is a notable north-south divide in the incidence of such disorders, with more cases the further north you look. In the 1980s, Vitamin D was found to normalise blood glucose levels by increasing insulin release. Then, in the 90s, the link established between the seasons and glycaemia (blood glucose). Now, it’s been proven that adequate Vitamin D reduces the risk of type 1 diabetes because it suppresses acquired immunity. As for type 2, it can help decrease insulin resistance – the first feature of this increasingly common, and enormously costly, disease.

NEVERMIND THE STARSIGN

In the light of the above, you may wish to know that April is the least ‘lucky’ month in which to be born: should your birthday fall around that month, your mother will have spent the majority of her pregnancy without much exposure to sunlight – unless she’s been holidaying abroad, for instance.

Lately, there’s been an increased focus on the link between Vitamin D and athletic performance. Dr Graeme L Close, senior lecturer in sports nutrition at Munster Rugby, has been asking; Why do jockeys (known for their leanness) have far lower levels of Vitamin D than their bulkier counterpart athletes, rugby players? He is testing the hypothesis that Vitamin D has a role in muscle mass. Certainly, ballet dancers who are given supplements of the vitamin (rather than a placebo) were found to be able to increase their vertical jump height and lower their injury rate; not a bad pointe (sic).

INDOOR LIVING: A TICKING TIME BOMB?

We know that lifestyle changes over the past 50 years have affected our health for the worse, immeasurably, as seen in obesity and diabetes epidemics. Are we facing a ticking time bomb of Vitamin D deficiency, which is storing up problems for later life in our children and young adults? Perhaps we should get kids outside with their handheld devices, and take full advantage of ‘wireless’.

Further research into Vitamin D’s effects on health is needed. A key issue is controlling such trials effectively, because Vitamin D isn’t like a measurable drug which can be monitored precisely, because we synthesis it from our exposure to sunlight. Yet, the message is ‘don’t’ give up’. Afterall, it took 40 years for the medical world to accept that sunshine would prevent rickets. In the meantime, we can take comfort that with the long winter ahead, dark chocolate is high in this precious vitamin. Now that’s a win-win situation….

Last week, I attended a talk for people involved in healthcare communications to hear how ‘nudge theory’ is being used at the Department Of Health to change health behaviours and improve outcomes. Definitions vary, but essentially, nudge theory is the use of suggestion or reinforcement to achieve non-forced compliance. Think toilet blocks in urinals to encourage better aim, or charging for plastic bags to shift shoppers to ‘save the planet and bring your own’. It’s not exactly rocket science, yet the subtleties involved in how groups of people can be nudged in a healthy direction for the long-term are intriguing, and can be explored in Nobel prize-winning Daniel Kahneman’s bestseller, Thinking, Fast and Slow.

It must be said that to the uninitiated, there’s a rather intimidating level of jargon in the behavioural insights lexicon: Terms such as ambiguity effect, inter-temporal choice and cognitive dissonance, but the key concept is that we are all affected by a range of ‘mental shortcuts’ which often help us, but can also lead us astray. Behavioural insights involve how people behave in real life – even when it may appear ‘irrational’.

But back to the jam-packed audience gathered at 34 Smith Square on a cold January night. With wine glasses clutched all round, Department of Health nudge guru, Dan Berry, asked wryly if a ‘dry January’ was being had by all, and by the time he’d taken up his laser pointer, the room’s cold Georgian windows were streaming with our seasoned breath.

YOU’VE BEEN MESSAGE-FRAMED

Unless you’re remarkably healthy, you cannot fail to have noticed that NHS hospitals are sending patients appointment reminders via text message. This is not for the sake of our convenience; they are an attempt to cut down the 1 in 10 appointments missed – at a cost of around £225 million per year. Through trial and error, involving randomised controlled trials, no less, the nudgers got their message framing right, and at the end of these SMS messages reads the statement, ‘Not attending costs NHS £160 approx.’ The results are not to be sniffed at. This carefully designed wording meant missed appointments fell by 23% – at a marginal cost of just 1.8p per time.

NHS Text Message Appointment Reminder

‘SIGN YOUR NAME ACROSS MY SCRIPT’

Aside from message framing, reciprocity is a key tool to achieve specific nudge goals. An interesting pledge scheme has started to be rolled out in an attempt to tackle the NHS’s £500 million cost of drug non adherence by patients. When collecting their medicines at the pharmacy, patients are asked to sign a pledge to take their medicines as prescribed, or else seek GP or pharmacy advice if concerned. There are a myriad causes behind patients not taking their drugs as prescribed, and often reasons that can be logically justified by the patient to themself – but less so to those holding the purse strings. One member of the audience told how her elderly father suffering from COPD had frequent appointments to keep his symptoms under control. Yet, when given antibiotics to avoid developing pneumonia, he refused, believing that ‘taking them now means they won’t work if I’m really ill’. Human thinking is complex and there is no one-size-fits-all solution, though there are well known socio-economic and gender biases that influence if and how nudges are interpreted. The good news is that early indications of this scheme show a 10% improvement in compliance in those who’d signed the pledge. (And who knew that in a digital age, good old fashioned pen and ink could be so powerful…)

NUDGED – OR MANIPULATED?

As far as healthy eating is concerned, nudge can be a powerful tool. One delegate asked whether the NHS should go head-to-head with commercial organisations that sell junk food, which to me was a prescient question. Without the marketing and advertising budgets of said parties, we need all the help we can get to discourage ‘eat now, diet later’ behaviour which is steeped in evolutionary pressures, as outlined in our obesity blog. Indeed, I’d take his question one step further. Only yesterday, Curious PR’s digital experts were discussing the power of remarketing, whereby web users are targeted according to their web search history, and nudged with relevant advertisements, accordingly.

Perhaps we’ll see a time when healthy living messages are served up to people buying unhealthy foods or drinks online. Unless, it turned out, the strategy backfired with accusations of ‘big brother’ tactics, as mooted by another member of the audience. For sure, the ethics committee will remain fully on board the ‘nudge bus’, partly because ‘manipulation’ isn’t a million miles from ‘helpful influencing’. (Naturally, Berry preferred the term ‘influence’, and pointed out that people don’t wish to develop diabetes but ‘everyday life got in the way’: It’s hard to turn down cake when it’s on offer.)

The Western world faces some tough choices here if we’re to succeed in tackling the major causes of disease and ill health today, most of which are preventable. (Unless antibiotic resistance makes infection disease come back with a bang). It could be said that we are all like snooker balls, being nudged from all sides by cushions, cues and other balls. But will we reach the right pocket? Having worked in financial news through the stock market boom and bust of the ‘90s and ‘00s, I have a profound belief that people are very like sheep. Get the right sheep to move in the right direction, at the right speed, and you’ll eventually get them in the pen. But even the best shepherds need experience, a well-trained dog, and the right kind of whistle.

NUDGED AWAY?

Berry’s presentation was refreshingly honest: we still don’t know the full potential of the power of nudge when it comes to improving healthcare outcomes – be that by getting people to turn up for NHS appointments, or asking GPs to consider prescribing a cheaper formulation of antibiotic (a suspension rather than an infusion, for example). In conclusion, I think we should be proud that along with the USA and Australasia, the UK is having a having a good stab at nudge.

TOP TIP: THINK E.A.S.T.

There are four ways behavioural insights should be applied: Easy, Attractive, Social, Timely – and that’s according to the Behavioural Insights Team (formerly part of the Cabinet Office, now a listed company). Again, it isn’t that difficult to get in the ‘Easy’ or the ‘Simple’. When NHS Health Checks were first launched, long and detailed letters went out to patients explaining what’d be involved, and asking them to book a check. Uptake was poor, so letters are now no longer than one paragraph, and have proven far more successful. There’s an element of ‘game framing’ in there too, with the words, ‘‘Please call XXX as soon as possible to make sure you get your appointment.” The less is more approach can be a powerful thing, and I have no doubt that many of us communications professionals could learn from it!

The English language is full of references that link guts and brains -‘I feel gutted’, ‘What’s your gut reaction?’, ‘That news left a bad taste in my mouth’, and so on. Even the old adage, ‘The way to a man’s heart is through his stomach’ emphasises the importance of a feeling well fed to how we feel emotionally. Yet, the complex, highly evolved biological interplay between brain and gut is, surprisingly, only now being fully unravelled to reveal its intriguing secrets. Much of this interplay is dictated by the microbes we play host to, especially the bacteria. And since the human body has 10 times more microbes than human cells, perhaps it’s a case of, ‘The way to a man’s heart is through his brain via his stomach – with help from the right bacteria’.

Increasingly, scientists are finding that what’s inside our guts will impact on our behaviour and emotions – as well as our long-term health, even influencing our risk of developing conditions such as Alzheimer’s. And with levels of depression,anxiety and obesity at record levels in Western society, we’re hungry to know more. And who knows; in future, we may be able to tackle psychological or emotional disorders via treatments that target the gut, rather than the brain or nervous system.

I embark on this blog having finished the highly entertaining best-seller,Gut: the inside story of our body’s most under-rated organ,by young medic, Giulia Enders. It caught my eye in the window of a bookshop whilst suffering from something of the gastric variety. This I blamed on being too curious and trying raw shellfish at an Italian wedding. ‘When in Rome’, I had thought, tucking in… Fast forward two months, and I set aside my normal concerns about antimicrobial resistance, and embarked on a course of antibiotics to try to end the symptoms. Later on, in an attempt replace some of the ‘good bacteria’ I’d nuked, I took a course of well-researched probiotics. Whether due to the probiotics or other factors, fortunately, after three months, my symptoms subsided, and, with them, an accompanying gloom which often goes with a gastric complaints – and for reasons Enders’ book helped to explain.

WE ACT WHAT WE EAT

Which brings us back to the book. Giulia Enders’ fascination with the gut was partly triggered by attending a medical student party, during which she chatted to a fellow student with the worst bad breath she’d ever encountered. Enders was soon to learn that the poor young man died only hours later, having taken his own life. Was there a link between his severe depression and the contents of his gut emitting those foul gases?

Despite its tragic start, the book is littered with scatological humour to keep things light, childish jokes about poo and puke, and ‘cute’ line drawn illustrations by the author’s sister. But, there are some serious, take-home facts woven through. Suddenly, the world is waking up to the links between our behaviour and what we eat. This goes far beyond questions such as, ‘Have you consumed too much caffeine today, Mr Tetchy?’ and into the fascinating realms of what we eat, how we eat (leisurely, or in a rush), how we expel its waste (sitting or squatting) the antibiotics we are exposed to, and other factors can influence weight-gain, obesity, and major lifestyle diseases including depression and anxiety.

‘ZOMBIE’ MICE: A CURIOUS TALE OF WHAT WE EAT

A particularly fascinating example that Enders gives involves the parasite, Toxoplasma Gondii, – single celled organisms that reproduce in the gut of cats, and can infect humans should they eat raw or unwashed food. (We can only be infected once, and the chance of us having been infected is the same as our age, in percentage terms.) Whilst initial infection may only produce flu-like symptoms, toxoplasmata can infect the brain of the host, and interact with neurotransmitters there to influence behaviour.

In an example of evolution at its most sophisticated, toxoplasmata modify dopamine and serotonin pathways such that infected mice are led towards cats in ‘suicidal fashion’ thanks to a reversal of their normal aversion to the smell of cat urine – ensuring cat can eat mouse, thus perpetuating the infection cycle. Humans who’ve been recently infected are more likely to be involved in a road traffic accident, or other event involving judgement of risk. Indeed, its effect on the brain is such that the proportion of toxoplasmosis carriers among schizophrenics is about double that seen in non-schizophrenics.

In Enders’ words, “Toxoplasmata can influence us far more than we ever thought possible a few years ago: And they have rung in a new scientific age: an age in which a crude lump of cat faeces can show us how susceptible our lives are to change…. we are just beginning to understand just how complex the connections are between us, our food, our pets, and the microscopic world in, on, and around us.”

The following nuggets are more than simply food for thought. At Curious PR, we predict they will increasingly influence healthcare priorities, policy and treatment in the future.

EXPOSE THEM YOUNG

Establishing good gut bacteria in childhood is crucial, which points to more cautious use of antibiotics in infants and children. Indeed, for anyone who is pregnant and faces the certainty of a C-section, it’s worth knowing that naturally-delivered babies receive their first major immune ‘event’ by being bathed in the secretions of the mother’s birth canal. Specifically, the lactic acid found naturally in this region provides a first, important step towards priming baby’s immune system, and thereby avoiding allergies as well as infections. Newborn C-section babies may have beautifully shaped, un-squashed heads, but for the first 3 years of life, they will lack the gut bacteria found in babies delivered normally. (Bear in mind, some UK hospitals have a 25% C-section rate.) As such, some parents now choose to wipe their newborn C-section babies with the mother’s birth canal secretions to try to simulate this event.

SQUEAKY CLEAN’S BAD

Mice reared in sterile surroundings (to eliminate normal bacterial colonisation of the gut) become obese, and their behaviour becomes hyperactive. Yet, injecting the stomach contents of a ‘normal’ mouse into that of its ‘squeaky clean’ counterpart will normalise the ‘clean’ mouse’s behaviour and body mass. Furthermore, if a thin mouse is given the gut bacteria of a fat human, it too gets fat. Now, one needn’t be a scientist to note the implications… A study involving mice twins, published in Science in 2013, provided solid evidence that the gut microbiome (its organisms and their genetic material) is involved in weight gain. The foods we eat (or don’t eat) influence which types of bacteria and in what numbers they exist, in our guts. Experts are asking whether changing our gut bacteria could influence the foods we crave, and therefore whether or not we become obese or overweight. Not so much ‘chicken or egg?’ but ‘chicken or donut?’

DIRT IS GOOD

So, how far should we go to promote a healthy bacterial balance? Experts on the side of ‘the hygiene hypothesis’ believe our daily lives have swung too far in the hygiene direction, which has starved us of regular contact with ‘helpful’ microbes. So, how about embracing the ‘Don’t Wash Your Hands’ theory? A recent article in The Times quotes Tim Spector, professor of genetic epidemiology at King’s College London on the subject of domestic hand hygiene. ‘I don’t think we should be washing out hands before a meal now. Food poisoning incidences in the home are incredibly rare. We are over-cleaning enough… We have to start striking a different balance because our sterility is causing problems.’

IT’LL ALL COME OUT IN THE WASH

In conclusion, it’s worth remembering that a sizeable 4lb (approximately 2kg – more than our brain weighs) of our gut contents consists of bacteria. They are highly important 2kg contribution to our health, and we must learn more about their link to metabolism, obesity, and other areas of health – including, ultimately, whether we are happy, fit and healthy. Enders makes some compelling arguments for not throwing the baby out with the bathwater, and keeping the right balance of bacteria in our lives. Yet, it’ll take major changes in attitudes and habits to achieve this, in cultures where the Victorian idea that ‘cleanliness is next to godliness’ prevails.

Without wishing to sound critical or mean spirited, my week’s holiday surfing and relaxing on the English coast this summer came as quite a shock, and it wasn’t the weather. On reflection, I felt it worth sharing what I see as the naked truth – from a healthcare communications point of view: Beach holidays reveal a lot about the state of the nation’s health, albeit a view from the exterior with no medical diagnostic tools to hand. Britain is in the thick of an obesity crisis, with diabetes rising in parallel, but we still aren’t talking about it nearly enough.

You need only compare photos of beach life taken in the 1970s and 80s (main photo: my brother and me in Devon, 1985) with those of today to appreciate the scale of change that’s taken place in relatively few years. My week of admittedly unscientific polls ‘from behind the windbreak’ consistently put the rate of overweight or obese people holidaying on the South West coast at around 60%. Now, even though I keep up to date with health issues, and am acutely aware that I live and work in the ‘bubble’ that is London, within the affluent South East, I was shocked by ‘in the flesh’ evidence of the drastic change in the shape of men, women, and children.

2014 Beach Scene

LOST GENERATIONS?

Seeing the rise in children who are overweight or obese is particularly depressing, given the likelihood that their BMI won’t fall, and knowing how the related psychological and physical burdens can compound to bring about many disadvantages in life. We’ll come to those later, suffice to say there are 4.5M children and young people in the UK who are overweight or obese. This includes over a fifth (22.5%) of Reception year children aged 4 – 5, with boys being more likely to be obese than girls in both Reception and Year 6 (age 9 – 10). As experts in healthcare communications, it’s a pertinent fact that most parents of an obese child are in denial about it.

The speed of change is daunting. A 2013 study saw hospital admissions for obesity and related health problems in children and young people rise more than four-fold from the previous decade – particularly among girls and teenagers. We also know that being an overweight child is linked to bullying – nothing new there – but consider this: In 2003 a US study concluded that the health-related quality of life of obese children and adolescents was similar to those diagnosed with cancer. It seems ironic that we read far more in the media about extremely underweight girls being admitted to hospital, than overweight girls (which is not to underplay the former).

Obesity is strongly linked to anxiety, eating disorders, depression and other mood disorders, especially in women. Aside from its well-documented effects on cardiovascular health, obesity affects women and girls in ways that are profound. It causes girls to start having periods earlier because adipose tissue (fat) contains aromatase – an enzyme that converts androgen precursors to oestrogen. (Conversely, in boys, obesity may cause delayed puberty, which can in turn cause psychological problems.) It also causes menstrual, fertility and pregnancy problems, including pre-eclampsia, eclampsia and miscarriage – as well as increased maternal and infant mortality, and gestational diabetes. (Curious PR predicts we’ll be hearing more about these less well-known obesity side effects in the future.)

But no discussion of obesity is complete without considering the Type 2 diabetes epidemic; they are two sides of the same coin, yet nobody has found a solution to reverse these unwelcome and costly trends. The chief executive of the NHS, Simon Stevens, has talked of the potential for diabetes to bankrupt the NHS eventually: “Obesity is the new smoking, and it represents a slow-motion car crash in terms of avoidable illness and rising health care costs.” According to the NHS, If current trends persist, 1 in 3 people will be obese by 2034 and 1 in ten will develop Type 2 diabetes. It is finally sinking in that one pound in every 10 spent by the NHS goes towards treating patients with diabetes, so It will be interesting to watch how the NHS Diabetes Prevention Plan is launched in April 2016, from a PR perspective.

THE FAT OF THE LAND

The Plan will attempt behavioural interventions that support people to maintain a healthy weight and be more active. But some obesity crisis observers call for ‘less nanny state’ and more ‘short, sharp shock’ to encourage behaviour change. Whilst controversial, the hard-hitting TV advertising campaign of 1987 narrated by John Hurt – ‘AIDS – Don’t die of ignorance’ – did terrify many into reducing risky behaviour overnight (albeit that HIV affects only around 0.15% of the UK population compared to 25% for obesity and 6% for diabetes.)

Back on the beach, and feeling depressed about ‘our fat future’ black humour stepped in and I headed to buy an ice cream from the café despite the long queue. Reaching the front of the line for elderflower sorbet, I was asked, “Child or adult size?” Having glimpsed an adult departing with 3 huge scoops in a large cone, I opted for “child ” – a portion that easily weighed 200g. One solution being tried by the food industry and other stakeholders is reduced portion size, but clearly, this café was having none of it! What I was more struck by however was that the queue hadn’t shortened all day: This beach – and countless others – may once have provided sunbathing, swimming and surfing, but it was now a grazer’s paradise.

SNACK ATTACK

Grazing is everywhere and it’s constant. Snacks are usually conveniently packaged for long shelf lives, so are often high calorie, low nutrient foods with high sugar levels, much like fizzy drinks. On the sugary drink front, certain nations are attempting to tackle their obesity via a sugar tax. Amongst these is Mexico which has set the levy at 10%, and public health experts report it’s having positive effects, but on the whole though, the jury is still out on this policy. Closer to home, chef-turned-campaigner, Jamie Oliver, has ruffled feathers via Channel 4 documentary, Jamie’s Sugar Rush, during which he witnesses surgical removal of children’s teeth made rotten by the white stuff. On the subject of obesity, he is clear: “Every clever person I have met realises we’re all aligned in the same catastrophe.” For sure, Jamie’s work is cut out. Snacks have become so much part of our culture, our leisure and lifestyle that mealtimes have taken a back seat. I was intrigued to hear one of our French clients note that the difference between how people ate in France versus the UK lay not in what was eaten: “French girls don’t snack”. (Only 12.9% of the French are obese, versus our 25%. (Smoking as a substitute for snacking was not discussed…) So, could Britain’s ‘snacking culture’ somehow be reversed? Afterall, evolution cannot move anything like as fast as cultural change, and it’s evolution that is winning out: High energy food is irresistible to most of us, because our ancestors were biologically adapted to survive times of famine. This renders willpower essential for maintaining a healthy weight in today’s times of plenty.

As mammals, we have a predilection for high calorie foods, with a particular penchant for a 50:50 mix of sugar and fat. Think donuts, ice cream and chocolate. (Intriguingly, this combination of nutrients is found nowhere in nature.) When it’s on offer, our neurological reward systems are set ablaze, and it’s hard to stop eating, even if our conscious brain taunts, ‘A moment on the lips, a lifetime on the hips!’ Indeed, lab experiments involving rats which are given separate bowls of sugar and butter don’t gorge on one or other food, whereas their fury counterparts offered a blended 50:50 mixture rather than separate bowls of fat and sugar tend to gorge until they become overweight, obese, and possibly insulin-resistant (pre-diabetic or diabetic). Such observations have lead to over-eating being labelled as an ‘addiction’. In an article entitled ‘Obesity is an incurable disease’ for The Guardian, George Monbiot notes in a somewhat crude analogy that only 10-20% of people who use crack cocaine become addicted, whereas a study of 176,000 obese people saw 98% fail to reach a healthy weight. Monbiot points the finger sharply at the junk food industry and at advertisers, but in fact there are multiple stakeholders involved. Labels, semantics and blame aside, we need solutions, and we need them fast.

THE ELEPHANT IN THE ROOM

In attempting to know why our obesity epidemic isn’t budging, we see one clue in a recent study that analysed the records of several thousand obese patients, and found 80% had never talked to their GP about their weight. This would suggest GPs are reluctant to discuss ‘the elephant in the room’ for fear of offending patients, and in a way, who could blame them? Or perhaps they are too focussed for various reasons on treating symptoms – not causes or solutions. Either way, experts point to the need for primary care professionals to seek training in obesity care. With the leading causes of morbidity and death being largely preventable these days we believe behaviour change is the crux, and healthcare needs to factor it in further. Perhaps, as with depression, over time, obesity will become less of a taboo subject to HCPs, with the upside that more cases can be identified and treated through a range of interventions. What is clear is that multiple stakeholders need to get together to find practical solutions – for all of us – and for the long term. The sheer size of this issue means a fatalistic attitude is not going to work – for any of us.